International Journal of Surgery Open 10 (2018) 1e4

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International Journal of Surgery Open

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Research Paper

Effectiveness of conservative management of uncomplicated acute appendicitis:

A single hospital based prospective study
Mumtaz KH. Alnaser a, Qays A. Hassan b, *, Laith N. Hindosh a
a
Department of Surgery, Al-Kindy College of Medicine, University of Baghdad, Baghdad, Iraq
b
Section of Radiology, Department of Surgery, Al-Kindy College of Medicine, University of Baghdad, Baghdad, Iraq

a r t i c l e i n f o a b s t r a c t

Article history: Background: Acute appendicitis is one of the commonest causes of acute abdomen. There is a wide
Received 8 November 2017 discussion and controversy on the surgical and nonsurgical treatment of acute uncomplicated appen-
Received in revised form dicitis. The aim of this study was to evaluate the efficacy and outcomes of the conservative management
19 November 2017
of selected cases of acute appendicitis with an antibiotic first plan.
Accepted 19 November 2017
Available online 6 December 2017
Patients and methods: This was a single hospital-based prospective study with a duration of 25 months.
Patients with clinical and radiological features of acute appendicitis presenting within 72 h of the
beginning of abdominal pain with Alvarado score
5 were included. The patients received a therapeutic
Keywords:
Acute appendicitis
dose of broad-spectrum antibiotics and symptomatic treatment. The follow-up period was 6 months.
Conservative treatment Results: 90 patients were evaluated, 54 (60%) patients were female and 36 (40%) patients were male with
Surgery mean age 34.4 years. Conservative treatment was successful in 68 (75.6%) patients and failed in 22
Antibiotics (24.4%) patients. No mortality recorded in this study. The main complications which occurred in those
patients who failed to respond to conservative treatment were perforated appendicitis (3 patients),
appendicular abscess (3 patients) and appendicular mass (4 patients).
Conclusion: Majority of cases of the first attack of uncomplicated acute appendicitis can be treated
successfully by conservative treatment. However, conservative treatment demands precise communi-
cation, close monitoring and follow-up to recognize failure which needs to be treated immediately by
surgery.
© 2017 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction Surgery may be associated with a longer hospital stay and

Acute appendicitis is one of the most common surgical emer-
gencies seen in general surgery practice. Complications can be severe
and include perforation and generalized peritonitis. Currently, ap-
pendectomy has been the primary treatment, even in cases of un-
confirmed diagnosis, given the low incidence of major complications.
However, in 15e30% of cases the appendix is found to be free of
disease upon resection [1,2]. Appendectomy can result in many
complications such as surgical wound infection, intestinal obstruc-
tion due to adhesions, pneumonia, and tubal infertility in females.
Non-operative treatment of an uncomplicated acute appendi-
citis has safety implications. But delaying surgery may increase the
risk of perforated appendicitis, intra-abdominal abscesses, and
localized or diffuse peritonitis.
* Corresponding author. Baghdad University, Al-Kindy College of Medicine,
Al-Nahdha Square, 10071, Baghdad, Iraq.
E-mail address: qtimeme@yahoo.com (Q.A. Hassan).
higher costs compared with nonoperative management with an-
tibiotics, but delayed treatment and a perforated appendix may
worsen morbidity, duration of sick leave and costs. However,
nonoperative management with antibiotics may be a cost-effective
alternative to surgery in a large percentage of patients without
increasing the risk and may reduce hospital stay and costs in both
developed and third world countries [3].
There is considerable discussion regarding the application of
conservative treatment compared with surgical treatment in
selected cases of acute appendicitis, as few studies have addressed
this issue to date [4,5].
The idea of application of conservative treatment on selected
cases of acute appendicitis is not new. In 1908 Alfred Stengel wrote:
“Treated in a purely medical or temporary manner, the great ma-
jority of patients with appendicitis recovery” [6].
Other reports state that immediate appendectomy can be
avoided for at least 24 h without increasing morbidity if antibiotics
are administered [7,8]. Other authors suggest that appendectomy
may not be necessary for the majority of patients with acute

https://doi.org/10.1016/j.ijso.2017.11.007
2405-8572/© 2017 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
2 M.KH. Alnaser et al. / International Journal of Surgery Open 10 (2018) 1e4

uncomplicated appendicitis, as the condition resolves spontane- without the need for surgical intervention and no appendicitis
ously without the need for a surgical procedure in many patients during a follow-up of 6 months.
and in others may be treatable with antibiotics alone [9]. This Failure of conservative treatment was divided into two sections.
approach has many advantages, including high success and low First, treatment failure which indicates a lack of clinical improve-
recurrence rates, reduced morbidity and mortality, less pain, ment, necessitating appendectomy while attempting conservative
shorter hospitalization and sick leave, and reduced costs [10]. treatment in the admitted patient. Second, recurrence which in-
The aim of this study was to evaluate the effectiveness of con- dicates repeated symptoms or disease within the follow-up period
servative treatment in uncomplicated acute appendicitis using of 6 months in an earlier successfully conservatively managed
antibiotic as a first treatment plan and to assess the treatment patient.
failure.
2.1. Statistical analysis
2. Patients and methods
Statistical package for social science version 20 (SPSS 20) was
This study was carried out in our hospital from January 2015 to used for both data entry and data analysis. Discrete variable pre-
December 2016. A total of 90 patients were enrolled in this study sented as number (%). Chi-square test (or fisher exact test when
based on the inclusion and exclusion criteria. Informed consent for appropriate) used to test the significance of association for the
all patients, as well as ethical approval for the study from the discrete variable. p-value of <0.05 were considered significant.
hospital scientific committee, were obtained. All patients above 16
years of age with a history of pain in right iliac fossa for less than 3. Results
72 h and clinically diagnosed as the first attack of appendicitis with
Alvarado score
5 (Table 1) were included in this study. Ultrasound In this study, 90 cases of uncomplicated acute appendicitis were
of abdomen and pelvis was done for all patients to confirm the included and managed conservatively. 54 (60%) patients were fe-
clinical diagnosis of acute appendicitis and to exclude the possi- male and 36 (40%) patients were male. Mean age was 34.4 year and
bilities of other intraabdominal pathologies. The specificity and range between 16 and 60 years. Table 2 show the age distribution of
sensitivity of ultrasound in our institution to diagnose acute the study. The maximum number of patients (40%) belonged to age
appendicitis was 86.6% and 86.5% according to recent study done by group 20e29 years.
Al-Marzooq et al. [11]. Sixty (66.7%) patients presented with signs and symptoms of
Exclusion criteria included recurrent appendicitis, patients acute appendicitis to the hospital with time interval 24 h, 18 (20%)
presented with complicated appendicitis such as perforation, ab- patients presented with time interval 24e48 h and 18 (20%) pa-
scess, mass on clinical examination or radiological reports, those tients presented with time interval 48e72 h as shown in Table 3.
who are lost during follow-up and patients unwilling for conser- In the 90 patients who were managed conservatively for un-
vative management, patients with a medical disease such as dia- complicated acute appendicitis, conservative treatment was suc-
betes mellitus and hypertension, immunocompromised patients, cessful in 68 (75.6%) patients with no treatment failure or recurrence
pregnancy and allergy to antibiotics. in the follow-up period of 6 months. However, in the remaining 22
All patients meeting the inclusion criteria then admitted to the (24.4%) patients, conservative treatment was failed. Treatment fail-
hospital and received intravenous antibiotics (cefotaxime 1 g twice ure during initial admission was seen in 10 patients (11.1%) whereas
daily and metronidazole infusion 500 mg/100 ml 3 times per day) recurrence was seen in 12 patients (13.3%) cases who were suc-
for at least 24 h. During this time patients received intravenous cessfully managed during primary admission (Table 4).
fluids, no oral intake with 6 hourly charts for (temperature, blood
pressure, pulse rate, respiratory rate and local abdominal sign). Table 2
Patients whose signs and symptoms had improved discharged Age distribution of the study.
home at the next morning and informed to continue with oral
Age (years) No. of patients (%) Mean age
antibiotics (ciprofloxacin 500 mg twice a day and metronidazole
500 mg three times a day) for a total of 10 days. In patients whose 19 6 (6.6) 17
20e29 36 (40) 26
clinical condition had not improved and did not respond to con- 30e39 24 (27) 34
servative treatment or worsened were operated by appendectomy. 40e49 18 (20) 42
Patients were told to contact immediately if pain recurs, vomiting 50e60 6 (6.6) 53
and fever had occurred. Follow-up at the end of treatment for six Total 90 (100) 34.4
months was done. Patients were told to inform us if they under-
went an operation in somewhere else.
Table 3
Successful conservative treatment was defined as being dis-
Number of the patients according to the duration of presenting symptoms.
charged from the hospital following the resolution of symptoms
Hours of attack of appendicitis No. of the patients (%)

24 h 60 (66.7)
Table 1
24e48 h 18 (20)
Alvarado score.
48e72 h 12 (13.3)
Score Total 90 (100)

Symptoms Migratory RIF pain 1

Anorexia 1
Nausea and vomiting 1 Table 4
Signs Tenderness (RIF) 2 Outcomes of conservative treatment.
Rebound tenderness 1
Outcome No. of the patients (%)
Elevated temperature 1
Laboratory Leukocytosis 2 Successful 68 (75.6)
Shift to left 1 Treatment failure 10 (11.1)
Total 10 Recurrence 12 (13.3)
 M.KH. Alnaser et al. / International Journal of Surgery Open 10 (2018) 1e4 3

Out of 22 patients who failed to respond to conservative treat-
ment, 10 patients were operated after 2 days of treatment, 5 pa-
tients were operated after completion of treatment course after 10
days and 7 patients were operated during the follow-up period of 6
months as shown in Table 5.
In the operated patients, 12 patients had acute suppurative
appendicitis, 3 patients had perforated appendix, 3 patients had an
appendicular abscess and 4 patients had an appendicular mass.
Our results showed that the gender, the age and the duration of
attacks of appendicitis had no significant association effects with
the outcomes of the conservative treatment as illustrated in Table 6.
4. Discussion
study results also agree with a recent study done in India in 2016 by
Gedam PS. Et al which involved 71 patients and showed a suc-
cessful rate 74.65%, treatment failure rate 14.08% and recurrence
rate 13.11 [15].
We used third generation cephalosporin and metronidazole in
all our patients treated conservatively. This was same as used in
most randomized control trials. Similar results were found by Vons
C et al. using amoxicillin plus clavulanic acid [16] and Turhan et al.
using ampicillin plus gentamycin [17].
Our results show that the gender distribution, the difference in
the age groups and the difference in time of presenting illness had
no significant effect on the outcomes of conservative treatment of
acute appendicitis.

Acute appendicitis is one of the commonest causes of acute 5. Conclusions

abdomen. Although appendectomy has been regarded as the gold-
standard, conservative management with antibiotics is gaining
more and more acceptance. There are many advantages of con-
servative treatment (i.e. antibiotic treatment) over surgical treat-
ment. Antibiotics give the chance to treat acute appendicitis when
surgical means are not readily accessible particularly in developing
countries and isolated areas. Conservative treatment is associated
with less cost effect balanced to surgery [12]. Antibiotic treatment
can reduce the mortality and morbidity risk associated with
surgery.
In the present study, 68 patients (75.6%) out of 90 patients were
treated with the conservative method and 10 patients (11.1%) failed
to respond to conservative treatment and had been operated and
further 12 patients (13.3%) show recurrence of appendicitis during
the follow-up period. So a total of 22 patients were failed to
respond and the failure rate was 24.4%. In a similar study done in
Sahlgrenska University Hospital (between May 2009 and February
2010) involving 442 patients show that 342 patients (77.4%) treated
conservatively successfully and 100 patients (22.6%) failed to
respond to conservative treatment [13], which nearly resemble our
study results. Another study which was done in the surgical
department of GMERS Medical College, Gandhinagar between years
2011e2013, that involve a sample of 30 patients undergoing con-
servative management show that 21 patients (70%) treated
conservatively successfully and 9 patients (30%) failed to respond
conservatively [14]. These results nearly resemble our results. Our
Table 5
Appendectomies after trial of conservative treatment.
Time of interval appendectomy No. of the patients (n ¼ 22)
Surgery after 48 h of treatment 10
Appendectomy after 10 days of treatment 5
Appendectomy within 6 months 7
This study evaluated conservative treatment in uncomplicated
acute appendicitis and was conducted in a single-based hospital for
a period of 2 years. Conservative treatment can be applied safely in
the majority of cases of the first attack of uncomplicated acute
appendicitis, therefore, avoiding appendectomy and its associated
morbidity and mortality. However, conservative treatment requires
close monitoring and repeated re-evaluation of the clinical condi-
tion of the patients to recognize a failure in improvement of clinical
status, which needs to be treated immediately by surgery. Treat-
ment failure on initial admission as well as the short-term recur-
rence after conservative treatment is low and acceptable.
Ethical approval
The ethical approval for the study from the hospital scientific
committee was obtained. The relevant Judgement’s reference
number is 111/2015 (Alkindy Teaching Hospital).
Funding
None.
Author contribution
Mumtaz KH and Qays A. contributed towards conceptualization
of study design. Mumtaz KH & Laith N. were involved in data
abstraction and analysis. Qays A. & Laith N. involved in preparation
of the manuscript. Mumtaz KH and Qays A. reviewed and edited
subsequent drafts and provided valuable feedback. All authors
approved the final version of the manuscript for submission.
Conflicts of interest statement

The authors declare that they have no conflict of interest.

Table 6
Outcomes of conservative treatment according to the gender and age distribution
and duration of attacks of appendicitis. Guarantor
Variables Outcomes of conservative treatment p-value
Qays A. Hassan.
Success Failure

Gender Male 26 (72.2%) 10 (27.8%) 0.72

Female 42 (77.8%) 12 (22.2%) Research registration number
Age group 20 4 (66.7%) 2 (33.3%) 0.84
21e30 33 (91.7%) 3 (8.3%) Research registry 3244.
31e40 18 (75%) 6 (25%)
41e50 10 (55.5%) 8 (44.5%)
51e60 3 (50%) 3 (50%) Appendix A. Supplementary data
Hours of attack 24 h 52 (86.7%) 8 (13.3%) 0.085
of appendicitis 24e48 h 11 (61.1%) 7 (38.9%) Supplementary data related to this article can be found at
48e72 h 4 (33.3%) 8 (66.7%)
https://doi.org/10.1016/j.ijso.2017.11.007.
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